RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02560
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080304

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Light Wheeled Vehicle Mechanic) medically separated for pain in her back, hips, knees, and feet.  These conditions could not be adequately rehabilitated to meet the requirements of her Military Occupational Specialty (MOS) or physical fitness standards, so she was issued a permanent U3-L3-S2 profile and referred for a Medical Evaluation Board (MEB).  The condition “chronic back, hip, knee and bilateral foot pains, secondary to stress reaction” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB (IPEB) adjudicated “chronic low back pain (LBP)…” and “Pain in hips, knees, and feet secondary to stress reactions” as unfitting, rated 10% and 0% (respectively).  The CI concurred with the PEB, but an administrative change was subsequently made to the PEB (Admin PEB); this correction incorporated administrative changes from the 2008 National Defense Authorization Act (NDAA), but kept the same rating codes and percentages of the IPEB.  Both the IPEB and Admin PEB apparently applied the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.  

CI CONTENTION:   The CI requested that the Board review all of her conditions.  The complete submission is at Exhibit A.   

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:  

Admin PEB – Dated 20080311	VA* - based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain…	5299-5237	10%	Lumbar Strain	5237	10%	STR	

Pain in Hips, Knees & Feet
	5022	0%	Stress Fractures…Left Leg	5299-5262	10%		
			Stress Fractures…Right Leg	5299-5262	10%		
			Bursitis, Right Hip	5019	NSC		
			Bilateral Knee Problems	5272	NSC		
			Bilateral Foot Pain	5010	10%		
Other MEB/PEB Conditions x 0 (Not in Scope)	Other x 3 	
RATING:  10%	RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20080806 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  The STR did not contain a VA Compensation & Pension (C&P) examination for the CI was reported as a “no show” for the scheduled appointment on 30 April 2008.  The pertinent historical medical information was obtained from an original VARD summary as well as case file clinical encounter documents.  

Chronic Low Back Condition.  There was a single clinical encounter document contained in the case file with regards to a back condition that indicated that the CI developed back pain after a ruck march and that a MEB was in progress.  X-rays of the lumbosacral spine were normal.  Her diagnosis was “LBP” and she was placed on quarters for 24 hours.  Her permanent profile dated 19 December 2009 contained numerous diagnoses that included “chronic back pain.”  At the MEB examination (21 October 2007; 4 months prior to separation), the CI reported recurrent back pain.  Her physical examination (PE) revealed full range-of-motion (ROM) of the back with noted tenderness about the lumbosacral muscle mass.  All neurologic parameters were normal.  Although X-rays of the low back were normal, nuclear medicine studies revealed “stress reactions” within the sacrum.  Her diagnosis remained chronic back pain secondary to stress reaction.  As previously noted, there was no VA examination available.  

The Board directed attention to its rating recommendation based on the above evidence.  Both the PEB and VA chose the primary VASRD code of 5237 (lumbosacral strain) and rated 10% citing tenderness of the lower spine.  Board members agreed that sufficient evidence of tenderness not resulting in an abnormal gait was present to justify the service’s 10% rating IAW VASRD §4.71a.  There was no evidence of an additional ratable neurologic impairment or documentation of VASRD-defined incapacitating episodes in this case which would provide for additional or higher rating.  Therefore, Board members agreed that a rating higher than 10% was not justified.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic LBP condition.

Hips, Knees and Feet Pain Condition.   A bone scan performed in February 2007 revealed mild stress changes in “the hips and knees”.  Additionally, plain film x-rays revealed sub-acute traumatic arthritic changes in the left mid foot second toe.  Her PE at the time of the NARSUM revealed tenderness to the outside area of both hips, the front aspect of both distal lower legs, and both mid feet  (left > right).  There was full ROM of both lower extremities.  “There is no evidence of atrophy, hypertrophy, edema, redness or ecchymosis in all areas evaluated from the lower back to the feet.”  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB chose to bundle the hips, knees, and feet together and assign 0% under VASRD code 5022 (periostitis).  The 6 June 2008 VARD indicated that the VA combined the bilateral foot pain and rated 10% under the traumatic arthritis code of 5010 as well as separately rated the bilateral stress fractures of the lower legs at 10% each.  The hip bursitis and any aspect of a knee condition were considered not service-connected (NSC).  
        
The Board first considered whether each lower extremity condition and its individual components (hip, knees, and feet) remained separately unfitting, having decoupled them from the combined PEB adjudication.  Since the CI subjectively and persistently endorsed pain in all lower extremity joints and only tenderness was found on the PE, Board members highly considered the corresponding diagnoses in this case in an attempt to determine fitness.  The bone scan findings of stress changes were considered equivocal to both hips and knees whereas the foot findings were indicated as left > right.  Board members considered the objective mild degree of pathology in all areas of the each lower extremity and concluded that it would be highly speculative to conclude that any disability confined separately to either lower extremity would not have rendered the CI incapable of performing her MOS duties; but, it is also reasonable to surmise that it was the combination of pathology from both lower extremities (hips, knees, and feet) that rendered her unfit.  After extensive deliberation, the Board conceded that the presence of persistent tenderness would best be rated as a complete bundled condition at a combined 10% impairment. 

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the low back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the bundled bilateral hips, knees, and feet conditions and IAW VASRD §4.71a, the Board unanimously recommends a bundled and combined overall 10% impairment rating under VASRD code 5022.  There were no other conditions within the Board’s scope of review for consideration.  

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:  

CONDITION	VASRD CODE	RATING	
Chronic Low Back Pain	5299-5237	10%	
Bilateral Hips, Knees, & Feet Pain 	5022	10%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140521, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB							
MEMORANDUM FOR Commander

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXX, AR20160003419 (PD201402560)

1.  I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA